Provider Demographics
NPI:1710706874
Name:SOUTH LA EYE CLINIC
Entity type:Organization
Organization Name:SOUTH LA EYE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MALDONADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-996-3507
Mailing Address - Street 1:646 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-7914
Mailing Address - Country:US
Mailing Address - Phone:760-996-3507
Mailing Address - Fax:442-271-4337
Practice Address - Street 1:231 W VERNON AVE STE 104
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-2778
Practice Address - Country:US
Practice Address - Phone:323-233-6271
Practice Address - Fax:323-233-8196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty